Clinical Images in Nephrology and Dialysis Acute Dyspnea in a Young Woman Following Percutaneous Nephrostomy Tube Placement Ei Khin , Ittay Moreno, and Indu Pathak KIDNEY360 2: 773–775, 2021. doi: https://doi.org/10.34067/KID.0006042020 Case Description extracorporeal shortwave lithotripsy, or bladder lacer- A previously healthy 16-year-old woman was admit- ation (3,4). It is a reversible condition once the un- ted to hospital for fever and dysuria for 1 day, and derlying disease process is resolved. However, at worsening of intermittent pain in the left costovertebral times, interventions may be required, including thora- area and left lower quadrant of abdomen for the last cotomy and pleural decortication (5). 3 days. Management consists of treating the underlying The patient denied urinary frequency, urgency, nau- uropathy and draining the pleural fluid via thoraco- sea, or vomiting. There was no history or family history centesis. The urinothorax resolved completely in our of kidney stones. patient after chest tube drainage and the misplaced On physical examination, the patient was noted to be nephrostomy tube was replaced with a new one, ap- an overweight adolescent with Tmax 102.9 F and mild propriately positioned in the collecting system. left costovertebral angle tenderness noted on abdomen examination. Laboratory results showed a white blood cell count Teaching Points of 12,700 cells/ml, erythrocyte sedimentation rate of 67 mm/hr, C-reactive protein level .18 mg/dl, and c A urinothorax should be suspected when patients serum creatinine of 1 mg/dl. develop dyspnea, chest pain, and unilateral pleural Urinalysis demonstrated moderate ketones and leu- effusion after having kidney or ureteral surgical pro- kocyte esterase, negative nitrites, numerous white cedures or with obstructive uropathy. blood cells, and 11 bacteria. Blood and urine cultures c The diagnosis can be made with a pleural fluid to were negative throughout hospital stay. Computed serum creatinine ratio .1.0 and an elevated pleural tomography scan of abdomen and pelvis (Figure 1A) fluid lactate dehydrogenase. revealed a wedge-shaped reduction in contrast en- c Early diagnosis and management will improve the hancement consistent with pyelonephritis, and patient’s outcome. a 6 mm stone obstructing the upper pole, left- collecting system. Intravenous ceftriaxone was admin- Disclosures istered for pyelonephritis, and the placement of per- All authors have nothing to disclose. cutaneous left nephrostomy tube drainage was done. The patient was diagnosed with a urinothorax, Funding which is defined as an accumulation of urine in the None. pleural space, and can be diagnosed by pleural fluid assessment and imaging. The pleural effusion in a uri- nothorax is straw colored, transudative, and has a urine Acknowledgments odor. The pleural fluid to serum creatinine ratio is Informed consent was obtained from the patient. .1.0, with elevated pleural fluid lactate dehydroge- nase. The fluid pH can be either acid or alkaline (1,2). Author Contributions A urinothorax is usually secondary to obstructive E. Khin conceptualized the study; E. Khin and I. Moreno uropathy and post renal and ureteral intervention wrote the original draft; I. Moreno was responsible for the procedures (3). It can also be seen after blunt kidney resources; and all authors reviewed and edited the trauma, kidney biopsy, kidney transplantation, manuscript. Department of Pediatrics, Texas Tech University Health Science Center El Paso, El Paso, Texas In-patient Department, El Paso Children’s Hospital, El Paso, Texas Correspondence: Ei Khin, Department of Pediatrics, Pediatric Nephrology, Texas Tech University Health Science Center El Paso, 4801 Alberta Avenue, El Paso, TX 79905. Email: [email protected] www.kidney360.org Vol 2 April, 2021 Copyright © 2021 by the American Society of Nephrology 773 774 KIDNEY360 AC B Figure 1. | Computed tomography (CT) scan of abdomen and pelvis. A CT scan of the abdomen and pelvis demonstrates a stone in the left upper pole of the kidney with associated pyelonephritis (A). On postoperation day 4, after left nephrostomy tube placement, the patient developed shortness of breath and her left chest pain increased in intensity to 10 out of 10, with dullness on percussion. (B) Chest roentgenogram (x-ray) demonstrates a large left pleural effusion on postoperation day 4. Ultrasound guided diagnostic pleurocentesis and left chest tube placement were done. The pleural fluid creatinine was 6.8 mg/dl and pleural fluid to serum creatinine ratio was 6.8, with pleural fluid lactate dehydrogenase of 316 IU/L. (C) CT scan of the abdomen and pelvis shows a percutaneous nephrostomy tube in the upper pole of the left kidney that is communicating with the pleural space with an associated pleural effusion. KIDNEY360 2: 773–775, April, 2021 Kidney Stone, Procedure Complication, Khin et al. 775 References Respiration 71: 533–536, 2004 https://doi.org/10.1159/ 1. Jain S, Jain D, Singh AK, Jain VK: An unusual presentation in 000080642 urinothorax. Indian J Chest Dis Allied Sci 58: 195–197, 2016 4. Salcedo JR: Urinothorax: Report of 4 cases and review of the 2. Austin A, Jogani SN, Brasher PB, Argula RG, Huggins JT, Chopra A: literature. J Urol 135: 805–808, 1986 https://doi.org/10.1016/ The urinothorax: A comprehensive review with case series. Am S0022-5347(17)45862-9 J Med Sci 354: 44–53, 2017 https://doi.org/10.1016/ 5. Bahjat AS, Sadeeq KJ, Tahir AMS, Mohammed AA: Urinothorax j.amjms.2017.03.034 causing massive left side pleural effusion in a young lady; case 3. 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